Electroconvulsive therapy (ECT) continues to be a critical and life-saving intervention for certain conditions, such as severe depression and other serious mental health disorders characterized by significant suicidality, catatonia, or the need for a swift therapeutic response^(1)(2)(3).

Electroconvulsive therapy (ECT) is a critical therapeutic approach for treatment-resistant mood and psychotic disorders when standard pharmacological treatments prove ineffective(3). Many patients undergoing ECT continue with maintenance therapy to prevent the relapse or recurrence of their psychiatric conditions⁽⁴⁾. Therefore, ECT is considered an essential service, the availability of which is crucial, particularly during the ongoing COVID-19 pandemic caused by SARS-CoV-2⁽⁵⁾.

The COVID-19 pandemic itself serves as a major source of stress for individuals, impacting health, employment, social support, and, for some, even basic necessities such as food and shelter⁽⁶⁾. As a result, there has been an increase in the onset of new psychiatric conditions and the exacerbation of pre-existing mental health disorders⁽⁷⁾.

The COVID-19 pandemic has severely disrupted the healthcare system including mental health care and has also adversely affected Electroconvulsive Therapy (ECT) services across the globe(8).The reasons include the risk of transmission of infections, lack of resources, and the scarcity of anesthesiologists due to their diversion to intensive care units to manage COVID-19 patients⁽⁹⁾. ECT practitioners globally have reported modifications and justifications in the triage and administration of ECT in reaction to competition for resources needed to provide ECT securely and in compliance with infection control procedures. The outcomes of patients will probably be impacted by such practice modifications⁽¹⁰⁾.

The study site, as the sole tertiary care institution in the state of Goa, serves as a crucial provider of mental health services, addressing the comprehensive psychiatric needs of the state’s population. In light of the unprecedented challenges posed by the COVID-19 pandemic, the institution made concerted efforts to ensure the uninterrupted delivery of Electroconvulsive Therapy (ECT), recognizing its essential role in the management of severe, treatment-resistant psychiatric disorders. The department implemented a range of stringent infection control protocols to mitigate the risk of SARS-CoV-2 transmission while maintaining the efficacy and safety of ECT administration. These measures included the restructuring of treatment schedules, adaptation of therapeutic procedures, and collaboration across multiple departments to ensure the continued availability of resources. Despite these constraints, the department was able to sustain its ECT services throughout the pandemic, underscoring its commitment to providing critical mental health care while adhering to infection control guidelines and prioritizing patient safety.

The primary aim of this study is to assess the impact of the COVID-19 pandemic on the administration of Electroconvulsive Therapy (ECT) at a tertiary care hospital in Goa, India. This includes evaluating any changes in the socio-demographic and clinical profiles of patients receiving ECT before and during the pandemic. Additionally, the study seeks to investigate whether any modifications were implemented in the administration of anaesthesia for ECT procedures during the pandemic, in response to the unique challenges posed by COVID-19. By addressing these objectives, the study aims to provide a comprehensive understanding of how the pandemic has affected the provision of this critical psychiatric treatment, as well as the adjustments made to ensure patient safety and continuity of care in a challenging healthcare environment.

This retrospective study was conducted at the Institute of Psychiatry and Human Behaviour, Goa, a tertiary mental health facility, where electroconvulsive therapy (ECT) is administered three days a week. IPHB is a tertiary care government psychiatry facility in the state of Goa that serves the state of Goa and the border areas of Maharashtra and Karnataka. It maintains individual running case papers of all the patients, in the MRD section. These case papers carry detailed information about each out-patient level visit, each admission, investigation and treatment provided and so on from the date of first registration.  All patients undergoing ECT are recorded in ECT registrar maintained by the ECT staff. This register was used to retrieve files of patients who underwent ECT.

Procedure

All the patients receiving ECT, during the years 2018 and 2022 were considered for the study. A total of 126 patients underwent Electroconvulsive Therapy (ECT) during the study period. The sample was divided into two groups based on the timing of their treatment: those who received ECT during the pre-COVID period (between 22 March 2018 and 21 March 2020) and those who received ECT during the post-COVID period (from 22 March 2020 to 21 March 2022). In the pre-COVID period, a total of 71 ECT sessions were administered, while 55 ECT sessions were provided during the post-COVID period. These two groups were subsequently compared. The study was approved by the Institute Ethics Committee. 

Table 1: Sociodemographic details

The socio-demographic characteristics of the participants were compared between the pre-COVID (2018-2020) and post-COVID (2020-2022) periods.

The mean age of patients in the pre-COVID group was 40.47 years, with a range from 18 to 64 years. In comparison, the post-COVID group had a lower mean age of 35.13 years, ranging from 23 to 54 years. The gender distribution was relatively consistent across both periods, with 47.89% of patients being male and 52.11% female in the pre-COVID period, and 49.09% male and 50.90% female in the post-COVID period.

Geographically, the pre-COVID group had a higher proportion of patients from rural areas (43.66%), followed by those from urban (33.80%) and semi-urban (22.54%) areas. However, in the post-COVID group, the distribution shifted, with a larger proportion of patients from urban areas (50.90%), followed by rural (27.27%) and semi-urban (21.82%) areas.

Regarding educational background, the pre-COVID cohort predominantly had education up to the 6th to 10th grade (36.62%) and a smaller proportion had completed higher education, with 7.04% being graduates and 2.82% holding postgraduate degrees. In the post-COVID cohort, the educational distribution was similar, with 34.55% having education up to the 6th to 10th grade, 20% up to the 1st to 5th standard, and 14.55% having completed the 11th to 12th standard. Graduates comprised 10.91%, while 10.91% had obtained postgraduate education.

Employment status remained predominantly unchanged across the two periods, with 76.06% of patients in the pre-COVID group being unemployed, compared to 74.55% in the post-COVID group. The employment rate in the pre-COVID period was 23.94%, and it slightly increased to 25.45% in the post-COVID group.

Regionally, the pre-COVID cohort consisted mostly of patients from Goa (77.46%), followed by those from outside Goa (19.72%) and outside India (2.82%). In contrast, the post-COVID group showed a higher proportion of patients from Goa (92.73%), with fewer from outside Goa (7.27%) and no patients from outside India.

Table 2: Clinical Outcomes and ECT Course Variables

In terms of ECT administration, 71 patients in the pre-COVID group and 55 patients in the post-COVID group received ECT. The pre-COVID group underwent a total of 513 ECT sessions, while the post-COVID group received 302 sessions. On average, patients in the pre-COVID group received 7.23 ECT sessions, whereas those in the post-COVID group received 5.49 sessions per individual.

A comparison of clinical characteristics and outcomes between the pre-COVID (2018-2020) and post-COVID (2020-2022) periods revealed several key differences. In terms of diagnosis, paranoid schizophrenia was the most prevalent condition in both groups, affecting 46.48% of patients in the pre-COVID group and 70.91% in the post-COVID group. Bipolar affective disorder (BPAD) and schizoaffective disorder were observed in 19.72% of patients in the pre-COVID group, but significantly fewer cases were recorded in the post-COVID group (BPAD: 3.64%, Schizoaffective: 7.27%).

Regarding complications, the most commonly reported issues in the pre-COVID group were headache (16.46%), dizziness (17.72%), and memory problems (6.33%). In contrast, the post-COVID group also exhibited a high incidence of headache (11.48%) and dizziness (13.12%), but with a notable reduction in memory-related complications (4.92%). Furthermore, the post-COVID cohort showed a higher proportion of patients with no comorbidities (52.46%) compared to the pre-COVID cohort.

The average seizure duration was slightly shorter in the post-COVID group, with a mean of 16.4 seconds compared to 17.3 seconds in the pre-COVID group.

With regard to anaesthesia agents, the pre-COVID group predominantly received a combination of GLP/PROP (81.09%), whereas the post-COVID group demonstrated a marked shift towards GLP/PROP administration (99.01%), with a minimal use of alternative agents.

There was a decrease in the mean BMI of patients from 27.32 kg/m² to 25.65 kg/m² taken for ECTs after the pandemic. Based on the American Society of Anesthesiology classification system, patients who belonged to grades I and II were preferred over patients who belonged to grades III.

Table 3:  Days required to initiate ECT

During the pre-COVID period, a larger proportion of patients (32.39%) received ECT within the second week, while 26.76% started within the first week. In contrast, during the post-COVID period, a greater number of patients (29.09%) began ECT in the third week, and only 14.55% received ECT within the first week. Notably, the post-COVID group exhibited a shift toward later initiation of treatment, with 18.18% of patients starting after more than four weeks, compared to 11.27% in the pre-COVID group.

Table 4: Days required to discharge the patient post ECT

The discharge patterns also showed significant changes. In the pre-COVID period, 32.39% of patients were discharged within the first week, and 33.80% within the second week. Conversely, in the post-COVID period, a much larger proportion (63.64%) was discharged within the first week. The second week saw a decrease in discharges, with 21.82% in the post-COVID group, compared to 33.80% in the pre-COVID period. By the third week, only 3.64% of post-COVID patients had been discharged, compared to 22.54% in the pre-COVID period. The mean length of hospital days following the COVID-19 pandemic was 36.7 days when compared to the pre-COVID statistics of 29.34 days.

PROTOCOL FOR ECT DURING COVID 19

Immediately after the Bharat Janta curfew, only emergency cases were taken in, and even non-emergency patients were administered ECTs after a month. We administered ECTs on Monday, Thursday and Saturday before the pandemic but after the pandemic, we administered only on Monday and Thursday for the first 4 months.

All patients posted for ECTs had to undergo RTPCR testing 1 day prior. Only if the result was negative, the patient would be taken up for ECTs. If the patient turned out to be positive, he would have to complete his quarantine period and be taken up for ECTs later.

When these patients were taken up for ECTs, we used a disposable main circuit, suction, cannula and mouth guards. The ECT machine and its electrodes, Bag Mask with tubing, Pulse oximeter and Blood pressure cuff with tubings were disinfected with 75% alcohol solution before every patient was taken up for ECT.

Every physician, staff nurse, and attendant were required to wear personal protective equipment (PPE) which contained a surgical cap, double gloves, an N95 mask, a gown, shoe covers, safety goggles and a face shield. The ECT unit facilities would undergo thorough cleaning, disinfection, and waste management following our hospital's instructions throughout the pandemic.

We had reduced the staff in the ECT room and social distancing was practised throughout the pandemic.

This research suggests that the availability of ECT was disproportionately affected by the COVID-19 epidemic, as it showed that sociodemographic factors, except age, did not significantly affect the amount of ECT administered. Future research on these variables will help medical facilities respond appropriately to pandemic-related situations and public health emergencies about procedural treatment.

After the pandemic, key finding of our study was the absence of significant differences in the diagnostic profile and distribution of patients who received ECT during the pandemic. Across both periods, psychotic disorders, such as schizophrenia and atypical psychosis, constituted the largest group of patients, followed by individuals diagnosed with manic episodes and depression. This finding contrasts with the findings of Oflezer et al., where the majority of the study population was primarily diagnosed with depressive disorders(8). Furthermore, thenumber of patients in this study who required emergency ECTsincreased after the pandemic which resembles the study of Kwan et al(10)

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Thenumber of patients who received ECTsand the total number of ECTs administered decreased after the pandemic which was similar tothe majority of the studies. This trend can be explained by the Central Government of India's implementation of movement restrictions and a restriction on ECT services because, when performed under anaesthesia, ECT can produce aerosols and there is a higher risk of transmission to other patients, staff members, and healthcare workers (12).

According to this study, hospital stays for ECT recipients during the COVID-19 pandemic were longer. The decline in regular ECT appointments may be related to the rise in the average length of stay. Furthermore, even when treatment was warranted, non-emergency ECT was not always administered during the pandemic, which caused problems for many patientsin the middle of ECT courses when the pandemic started (8).

The rise in the average length of stay can be attributed to the reduction in daily ECT appointments. Furthermore, during the pandemic, there was hesitance to initiate non-emergency ECT, even when clinically warranted, resulting in disruptions for numerous patients who were undergoing ECT treatments at the time the pandemic began(8)(13).

Recent guidelines have emphasized the importance of ensuring that patients undergoing Electroconvulsive Therapy (ECT) are asymptomatic for COVID-19. It is now recommended that each patient undergo SARS-CoV-2 testing close to the time of their procedure. This approach serves to identify individuals who may be harbouring the virus, even in the absence of symptoms. Importantly, patients who test positive for SARS-CoV-2 should not proceed with ECT, in order to mitigate the risk of transmission and ensure the safety of both patients and healthcare providers. In line with this, all procedures involving ECT should adhere to stringent infection control measures, and patients who exhibit signs of COVID-19 or test positive for SARS-CoV-2 should be deferred from undergoing the procedure until they are no longer infectious, in accordance with the latest public health recommendations. By incorporating these measures, we aim to safeguard both the wellbeing of our patients and the integrity of the clinical environment, minimizing the risk of SARS-CoV-2 transmission during ECT procedures (14).

Glycopyrrolate and Propofol were utilized as the primary anaesthetic drugs for ECT at our institute during the pandemic as drugs like thiopentone were not recommended since they can induce bronchospasm, apnoea, and respiratory depression. Compared to atropine, glycopyrrolate is a more effective drug at reducing salivation and aerosolization during the procedure and it also can’t cross the Blood Brain Barrier thereby reducing the extrapyramidal side effects. Glycopyrrolate 0.2 to 0.4 mg was used intravenously. In contrast, Surve et al had added anti-sialogogues in patients with profuse oral secretions during the first ECT(3).

Hyperventilation using bag-mask ventilation can improve seizure quality, however, the evidence for this is weak and it can increase aerosolization. Therefore, this strategy should be avoided during the COVID-19 pandemic unless adjustment to other measures to improve seizure quality is unsuccessful. Induction agents providing the best possible quality of seizure should be employed; these include ketamine, etomidate, and methohexital(15).However, due to the unavailability of these agents in our institute we continued to use bag-mask ventilation along with agents which reduce hypersalivation which in turn reduces aerosolization.

ECT needs to be regarded as a necessary medical therapy, even amid the COVID-19 pandemic. If it is based on a functional protocol, it may operate more safely and effectively. We urge every institute to create its protocol, working with a multidisciplinary team to ensure it is based on suggestions from both local and international healthcare organisations and scientific literature(13).

In conclusion, this study underscores the profound impact of the COVID-19 pandemic on the administration of Electroconvulsive Therapy (ECT) at a tertiary care institution in Goa, India. Despite the numerous operational challenges and disruptions to healthcare services posed by the pandemic, the institution was able to sustain ECT delivery by implementing stringent infection control measures and modifying procedures to prioritize patient safety.

The results revealed no significant changes in the diagnostic profile of patients receiving ECT before and during the pandemic, although there was a notable increase in the number of emergency ECT cases post-pandemic, reflecting a rise in the severity of psychiatric conditions during this period. Additionally, patients in the post-COVID group experienced delays in initiating treatment and longer hospital stays, likely due to the constraints imposed by COVID-19-related restrictions.

Key modifications in anaesthesia protocols, such as the use of Glycopyrrolate and Propofol, were crucial in mitigating the risk of aerosol transmission, ensuring the safe conduct of ECT procedures under the altered circumstances. Despite these necessary adjustments, there was a reduction in the total number of ECT sessions, consistent with a broader decline in the availability of healthcare services during the pandemic.

This study demonstrates the adaptability of healthcare systems in maintaining essential psychiatric services in the face of public health crises. It also emphasizes the importance of developing adaptable protocols and multidisciplinary approaches for the safe delivery of ECT in future emergencies. The model established in this study can serve as a framework for other institutions facing similar challenges in future global health crises, ensuring the continued provision of critical psychiatric care while safeguarding patient and staff safety.

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